Subacute Combined Degeneration of the Spinal Cord Caused by Autoimmune Gastritis

A 68-year-old woman presented with a 2-year history of worsening unsteady gait. Her neurological examination revealed peripheral neuropathy with lower limb sensory dominance. T2-weighted imaging revealed a disorder of the posterior cervical cord. Blood test findings revealed vitamin B₁₂ deficiency, and gastroscopy revealed typical findings of autoimmune gastritis. She received vitamin B₁₂ supplementation, but some peripheral neuropathy symptoms persisted due to longstanding vitamin B₁₂ deficiency. Asymptomatic patients should undergo gastroscopy to detect autoimmune gastritis, as chronic vitamin B₁₂ deficiency causes irreversible peripheral neuropathy.

Isolated subacute combined degeneration in late-onset cobalamin C deficiency in children: Two case reports and literature review

RATIONALE

Subacute combined degeneration (SCD) is a disease caused by decreased vitamin B12 intake or metabolic disorders. It is more common in the elderly and rarely seen in children. Here, we report 2 pediatric cases of SCD in late-onset cobalamin C (CblC) deficiency.

PATIENT CONCERNS

The patients complained of unsteady gait. Their physical examination showed sensory ataxia. Magnetic resonance imaging showed classic manifestations of SCD. The serum vitamin B12 level was normal, but urine methylmalonic acid and serum homocysteine levels were high.

DIAGNOSIS

The pathogenic gene was confirmed as MMACHC. The 2 patients each had 2 pathogenic mutations C.482 G>A and C.271dupA and C.365A>T and C.609G>A in this gene. They were diagnosed with combined methylmalonic acidemia and homocysteinemia-CblC subtype.

INTERVENTIONS

The patients were treated with methylcobalamin 500 μg intravenous injection daily after being admitted. After the diagnosis, levocarnitine, betaine, and vitamin B12 were added to the treatment.

OUTCOMES

Twelve days after treatment, the boy could walk normally, and his tendon reflex and sense of position returned to normal. The abnormal gait seemed to have become permanent in the girl and she walked with her legs raised higher than normal.

LESSONS

To the best of our knowledge, this is the first report of 2 cases of isolated SCD in children with late-onset CblC disorder. Doctors should consider that SCD could be an isolated symptom of CblC disorder. The earlier the treatment, the lower the likelihood of sequelae.

Sequential involvement of the nervous system in subacute combined degeneration

PURPOSE

Subacute combined degeneration (SCD) involves progressive degeneration of the spinal cord, optic nerve, and peripheral nerves. Vitamin B12 (VB12) is a co-factor in myelin synthesis. Because each cell that constitutes the myelin component in the central nervous system and peripheral nervous system is different, it is improbable that these cells undergo simultaneous degeneration. However, the sequence of degeneration in SCD has not been established.

MATERIALS AND METHODS

In this study, we analysed medical records and electrophysiological data of patients who showed neurological symptoms and whose serum VB12 levels were lower than 200 pg/mL.

RESULTS

We enrolled 49 patients in this study. Their mean VB12 level was 68.3 pg/mL. Somatosensory evoked potential (SEP) study showed abnormal findings in 38 patients. Of the 40 patients who underwent visual evoked potential (VEP) study, 14 showed abnormal responses. Eighteen patients showed abnormal findings on a nerve conduction study (NCS). In this study, abnormal posterior tibial nerve SEPs only were seen in 16 patients, median nerve SEPs only were seen in 3 patients, abnormal VEPs only in two, and abnormal NCS responses in one patient. No patient complained of cognitive symptoms.

CONCLUSION

In SCD, degeneration appears to progress in the following order: lower spinal cord, cervical spinal cord, peripheral nerve/optic nerve, and finally, the brain.

[Diagnostic significance of spinal cord conduction velocity in the diagnosis of central lesions in subacute combined degeneration]

OBJECTIVE

To study explore the roles of spinal cord conduction velocity (SCCV) test in the diagnosis of spinal lesions in patients with subacute combined degeneration (SCD) of spinal cord and examine the values of SCCV in the localization of spinal lesions.

METHODS

A total of 22 SCD patients recruited from 2005 to 2010 at our hospital underwent the SCCV test, the somatosensory evoked potential (SEP) test and MRI in spinal cord respectively. The results of SCCV were compared with those of SEP and MRI.

RESULTS

There were 16 males and 6 females with an average age of (56 ± 13) years old (range: 28 - 84). All SCD patients underwent the examinations of SCCV and spinal MRI. And 18 patients received the test of SEP. The abnormalities of SCCV test were 81.8% (18/22) and those of MRI and SEP 13.6% (3/22) and 72.2% (13/15) respectively. The results of SCCV and spinal MRI were both abnormal in 3 patients. Nineteen patients had normal MRI while 18 had abnormal SCCV results.

CONCLUSION

The early electrophysiological abnormalities in spinal cord of SCD patients may be detected objectively by SCCV. They appear earlier than those of pathological and imaging findings. The abnormal rates of SCCV are much higher than those of spinal MRI. The SCCV test can also help to localize the lesions in spinal cord of SCD patients. It may provide an objective diagnostic basis for the lesions of spinal cord of SCD patients at an early stage.